Integrated Capecitabine-Temozolomide with Radioembolization for Liver-Dominant G2 NETs: Long-Term Outcomes of a Single-Institution Retrospective Study.

PURPOSE: Capecitabine-Temozolomide (CapTem) is an oral chemotherapy regimen for NETs. Both drugs are radiosensitizers. Integrating CapTem and Y90 transarterial radioembolization (TARE) in patients with grade 2 neuroendocrine tumor (NET) liver metastases achieved an encouraging objective response rate (ORR) and progression-free survival (PFS) in a feasibility study. This study expands that report to a larger cohort with longer follow-up. METHODS: Therapy consisted of monthly cycles of capecitabine 600 mg/m2 twice daily for 14 days and temozolomide 150-200 mg/m2 on day 10-14. Simulation angiography was performed during the initial cycle. The dominant lobe was treated with 90Y-resin microspheres using BSA dosimetry on day 7 of the second cycle of CapTem. Patients with bilobar disease had the other lobe treated on day 7 of the third or fourth cycle. CapTem was continued until progression or intolerance. Clinical and laboratory assessment was done monthly and imaging every 3 months. RESULTS: 35/37 patients completed the prescribed regimen. Primary sites of disease were pancreas (16), lung (10), gut (7) and unknown (4). Mean duration of CapTem was 12 months (range, 4-32 months). ORR in the liver was 72% with a disease control rate of 100%. Median PFS was 36 months (95% CI, 25-45 months). Median overall survival was 41 months (95% CI, 24-87 months) from initiation of CapTemY90 therapy and 130 months (95% CI, 56-172 months) from initial diagnosis. CONCLUSION: Chemoradiation with CapTem and TARE provided durable control of G2 NET liver metastases for substantially longer than expectations for embolotherapy or chemotherapy alone.

Variability in biopsy quality informs translational research applications in hepatocellular carcinoma.

In the era of precision medicine, biopsies are playing an increasingly central role in cancer research and treatment paradigms; however, patient outcomes and analyses of biopsy quality, as well as impact on downstream clinical and research applications, remain underreported. Herein, we report biopsy safety and quality outcomes for percutaneous core biopsies of hepatocellular carcinoma (HCC) performed as part of a prospective clinical trial. Patients with a clinical diagnosis of HCC were enrolled in a prospective cohort study for the genetic, proteomic, and metabolomic profiling of HCC at two academic medical centers from April 2016 to July 2020. Under image guidance, 18G core biopsies were obtained using coaxial technique at the time of locoregional therapy. The primary outcome was biopsy quality, defined as tumor fraction in the core biopsy. 56 HCC lesions from 50 patients underwent 60 biopsy events with a median of 8 core biopsies per procedure (interquartile range, IQR, 7-10). Malignancy was identified in 45/56 (80.4%, 4 without pathology) biopsy events, including HCC (40/56, 71.4%) and cholangiocarcinoma (CCA) or combined HCC-CCA (5/56, 8.9%). Biopsy quality was highly variable with a median of 40% tumor in each biopsy core (IQR 10-75). Only 43/56 (76.8%) and 23/56 (41.1%) samples met quality thresholds for genomic or metabolomic/proteomic profiling, respectively, requiring expansion of the clinical trial. Overall and major complication rates were 5/60 (8.3%) and 3/60 (5.0%), respectively. Despite uniform biopsy protocol, biopsy quality varied widely with up to 59% of samples to be inadequate for intended purpose. This finding has important consequences for clinical trial design and highlights the need for quality control prior to applications in which the presence of benign cell types may substantially alter findings.

Infection Rates Following Hepatic Embolotherapy in Patients with Prior Biliary Interventions: Comparison of Single-Drug Moxifloxacin and Multidrug Antibiotic Prophylaxis.

PURPOSE: To investigate the incidence of infection in patients with prior biliary interventions undergoing hepatic embolotherapy following extended antibiotic prophylaxis using moxifloxacin monotherapy or a multidrug regimen. MATERIAL AND METHODS: Under an Institutional Review Board-approved protocol, retrospective review of a quality assurance database identified all liver-directed therapies (LDTs) at a tertiary care center between 2010 and 2019 with biliary intervention prior to LDT Records were reviewed for infectious complications within 3 months of chemo- or radioembolization. Patients were categorized based on extended antibiotic prophylaxis regimen: oral moxifloxacin monotherapy or multidrug regimen of levofloxacin and metroniodazole plus preprocedural neomycin and erythromycin. Procedures without at least 2 months of clinical follow-up, hepatic ablation, and procedures without extended antibiotic prophylaxis were excluded Regression analysis was used to analyze multivariate data to detect a difference in infection rate. RESULTS: Twenty-four chemoembolization and 58 radioembolization procedures were performed on 55 patients with prior biliary interventions. Forty-four used monotherapy and 38 used multidrug regimen. The incidence of infection was 16.7% (4/24) after chemoembolization and 13.8% (8/58) after radioembolization The incidence of infection in patients did not differ between antibiotic prophylaxis regimens (18.2% [8/44] with moxifloxacin monotherapy and 10.5% [4/38] multidrug regimen, P = .3) or between types of biliary interventions (24.1% [7/29] with bilioenteric anastomosis and 23.8% [5/21] biliary stenting, P = .3). CONCLUSIONS: The types of extended antibiotic prophylaxis (moxifloxacin monotherapy vs multitherapy), prior biliary intervention, and embolotherapy were not found to be associated with differences in the incidence of infectious complications in this population.

Chronic Hepatotoxicity in Patients with Metastatic Neuroendocrine Tumor: Transarterial Chemoembolization versus Transarterial Radioembolization.

PURPOSE: To compare the manifestations of chronic liver injury following transarterial chemoembolization with those of transarterial radioembolization (TARE) in patients with neuroendocrine tumor (NET). MATERIALS AND METHODS: This study consisted of an Institutional Review Board-approved single-institution retrospective analysis of NET patients who received transarterial chemoembolization from 2006 to 2016 and TARE from 2005 to 2014 and survived at least 1 year from the initial treatment. Patients receiving only transarterial chemoembolization (n = 63) or TARE (n = 28) were evaluated for the presence or absence of durable hepatic toxicities occurring at least 6 months after initial treatment. The definitions and grades of liver injury were adapted from Common Terminology Criteria for Adverse Events version 4.0 and were characterized by the presence of laboratory or clinical toxicities of Grade 3 or above. RESULTS: Chronic hepatic toxicity occurred in 14 of 63 transarterial chemoembolization patients (22%) with a total of 26 Grade 3-4 events, in whom elevation of bilirubin was the most common toxicity, compared to 8 of 28 TARE patients (29%) with a total of 16 Grade 3-4 and 2 Grade 5 events, in whom ascites were the most frequent toxicity. There were more laboratory toxicities in the transarterial chemoembolization group (65% vs 38%, P = .11) and fewer Grade 4-5 injuries (6% vs 27% of patients, P = .06). There was also a significantly higher number of patients who experienced intrahepatic progression of disease in the transarterial chemoembolization cohort than in the TARE patients (75% vs 43%, respectively; P = .005). CONCLUSIONS: Delayed hepatotoxicity from transarterial chemoembolization and TARE occurred in 22% and 29% of patients, respectively, from 6 months to several years following treatment. Transarterial chemoembolization-related toxicities on average were less severe and manifested primarily as laboratory derangements, compared to TARE toxicities which consisted of clinical hepatic decompensation.

Percutaneous Fluoroscopic-Guided Creation of Neoanastomosis for the Treatment of Biliary Occlusions.

PURPOSE: Complete biliary occlusions at different anatomic locations that are not amenable to surgical, endoscopic, or routine percutaneous methods pose a challenge to physicians. Biliary ductal neoanastomosis technique can play a very important role in solving such clinical problems. MATERIALS: Between October 2004 and January 2018, six patients were treated in our institution for biliary drainage using biliary ductal neoanastomosis technique via sharp recanalization and a staged approach to achieve internal/external biliary drainage. All procedures were performed in an angiography suite by an interventional radiologist after multidisciplinary discussion. RESULTS: The mean patient age of the cohort was 54 years and 50% of the patients were female (three/six patients). The cause of obstruction was complications or disease progression after  Whipple procedure in four patients, partial hepatectomy in one patient and benign biliary stricture after radioembolization in one patient. All patients were treated with percutaneous biliary neoanastomosis. All procedures were successfully performed in all six patients (100% technical success) without any major complications. All patients were successfully managed by capped drainage catheters for the duration of the follow up (one patient was transitioned to endoscopically inserted biliary stent, and in one patient the tube was eventually removed after establishment of patent neoanastomosis). CONCLUSIONS: Biliary ductal neoanastomosis is an effective treatment option when the anatomy has been significantly altered in the post-surgical setting and wire cannot be safely passed into target draining organ or the remainder of biliary system. When performed by an experienced operator, this technique is safe and effective with a high technical success rate.

Effectiveness of Liver-Directed Therapy for the Management of Intractable Hypoglycemia in Metastatic Insulinoma.

OBJECTIVE: The aim of the study was to evaluate efficacy of chemoembolization and radioembolization in treating patients with recurrent hypoglycemia secondary to metastatic insulinoma. METHODS: A retrospective review was performed of all patients with metastatic insulinoma treated with liver-directed therapy (LDT) at a large academic medical center from January 1998 to August 2017. Primary outcomes included blood glucose levels, occurrence of symptomatic hypoglycemic episodes, and tumor imaging response rates. RESULTS: Seven patients were identified (4 male patients). The mean age at the first LDT was 60.9 (standard deviation [SD], 9.2) years. The median follow-up was 1.8 years. Thirty-three sessions of LDT were performed including 30 sessions of chemoembolization and 3 sessions of radioembolization. Technical success rate was 97% (32/33 procedures) with an initial clinical success rate of 100%, defined as absence of recurrent symptomatic hypoglycemia within 1 month after first cycle of LDT and overall clinical success rate of 85%. Random daytime glucose levels increased from 75.0 (SD, 26) mg/dL to 152.8 (SD, 52.4) mg/dL after LDT. The mean time to recurrence of intractable hypoglycemia was 21 (SD, 9) months. No severe complications were reported. CONCLUSIONS: Liver-directed therapy with chemoembolization or radioembolization is effective for treatment of symptomatic hypoglycemia secondary to malignant insulinoma metastatic to liver.

Impact of PTFE-covered stent position and extension on TIPS patency.

PURPOSE: The objectives of this study were to determine the effects of expanded polytetrafluoroethylene (PTFE)-covered stent location and TIPS extension on primary patency. METHODS: This retrospective cohort study examined patients with PTFE-covered TIPS creation between 07/2002 and 06/2016. Clinical information and patency outcomes at 24 months were extracted. At TIPS creation, extension was performed at the discretion of the operator. Kaplan-Meier curves of primary patency were generated with conditional variables of HVO-HCJ distance, extension status, and covered versus uncovered extensions. Additional logistic regression analyses of distances were performed. RESULTS: Of 393 patients, 115 patients (29%) underwent stent extension, 79 (20% of total cohort) of which were at the HVO end alone. Primary patency for all TIPS was 75%, 68%, and 54% at 3, 6, and 12 months. The data endpoint were transplant or death in 92 (23%) and 116 (30%). Kaplan-Meier curves showed no statistically significant difference between the variables and primary patency at 12 and 24 months: distance up to versus greater than 10 mm (p = 0.32, 0.81); extension versus no extension (p = 0.83, 0.85); uncovered versus covered extensions (p = 0.58, 0.70). Logistic regression analyses showed a trend toward statistical significance. CONCLUSION: In the setting of PTFE-covered TIPS creation, extended TIPSs and unextended well-positioned TIPSs have no difference in primary patency rates. Stent position and extension length may have an effect on primary patency, but were likely obscured by "user recognition" effects.

Deep Learning Based on MRI for Differentiation of Low- and High-Grade in Low-Stage Renal Cell Carcinoma.

Pretreatment determination of renal cell carcinoma aggressiveness may help to guide clinical decision-making. PURPOSE: To evaluate the efficacy of residual convolutional neural network using routine MRI in differentiating low-grade (grade I-II) from high-grade (grade III-IV) in stage I and II renal cell carcinoma. STUDY TYPE: Retrospective. POPULATION: In all, 376 patients with 430 renal cell carcinoma lesions from 2008-2019 in a multicenter cohort were acquired. The 353 Fuhrman-graded renal cell carcinomas were divided into a training, validation, and test set with a 7:2:1 split. The 77 WHO/ISUP graded renal cell carcinomas were used as a separate WHO/ISUP test set. FIELD STRENGTH/SEQUENCE: 1.5T and 3.0T/T2 -weighted and T1 contrast-enhanced sequences. ASSESSMENT: The accuracy, sensitivity, and specificity of the final model were assessed. The receiver operating characteristic (ROC) curve and precision-recall curve were plotted to measure the performance of the binary classifier. A confusion matrix was drawn to show the true positive, true negative, false positive, and false negative of the model. STATISTICAL TESTS: Mann-Whitney U-test for continuous data and the chi-square test or Fisher's exact test for categorical data were used to compare the difference of clinicopathologic characteristics between the low- and high-grade groups. The adjusted Wald method was used to calculate the 95% confidence interval (CI) of accuracy, sensitivity, and specificity. RESULTS: The final deep-learning model achieved a test accuracy of 0.88 (95% CI: 0.73-0.96), sensitivity of 0.89 (95% CI: 0.74-0.96), and specificity of 0.88 (95% CI: 0.73-0.96) in the Fuhrman test set and a test accuracy of 0.83 (95% CI: 0.73-0.90), sensitivity of 0.92 (95% CI: 0.84-0.97), and specificity of 0.78 (95% CI: 0.68-0.86) in the WHO/ISUP test set. DATA CONCLUSION: Deep learning can noninvasively predict the histological grade of stage I and II renal cell carcinoma using conventional MRI in a multiinstitutional dataset with high accuracy. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.

Inferior Vena Cava Reconstruction in Symptomatic Patients Using Palmaz Stents: A Retrospective Single-Center Experience.

BACKGROUND: The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents. METHODS: From 2002 to 2019, 37 patients (mean age: 51 year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n = 25) and intrahepatic (n = 12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up. RESULTS: Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1 year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n = 5) was 1.2 year. Late lumen loss was (n = 13) was 40% during a mean time to follow-up of 2.0 years. Primary patency in patients with occlusion secondary to malignancy was 109 day (range: 1 day-1.0 year), whereas primary patency in patients with occlusion from other etiologies was 1.1 year (range: 2 day-5.9 year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months. CONCLUSIONS: Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.

Association of Complete Radiologic and Pathologic Response following Locoregional Therapy before Liver Transplantation with Long-Term Outcomes of Hepatocellular Carcinoma: A Retrospective Study.

PURPOSE: To evaluate long-term outcomes of patients with hepatocellular carcinoma (HCC) who show a complete response (CR) vs non-CR on pretransplantation imaging studies or pathologic evaluation of liver explants after locoregional therapy (LRT) before liver transplantation. MATERIALS AND METHODS: Patients listed for liver transplantation for HCC (March 1998 to December 2010) undergoing LRT with available multiphase MR/CT imaging before transplantation were included. Pathologic response was evaluated based on liver explant pathology. A total of 108 patients (17 women; 16%) met the inclusion criteria. RESULTS: Radiologic CR was achieved in 65 patients (60%) vs non-CR in 43 (40%), and pathologic CR was achieved in 36 patients (33%) vs non-CR in 72 (67%). Mean 5-year overall survival (OS) from the time of listing and recurrence-free survival (RFS) after liver transplantation were significantly better for patients with pathologic CR vs non-CR on explant pathology (OS, 83.3% vs 65.2% [28% difference; P = .046]; RFS, 80.6% vs 62.5% [29% difference; P = .045]). Mean 5-y OS and RFS were not significantly different between patients with radiologic CR or non-CR on pretransplantation imaging (OS, 75.4% vs 65.1% [P = .12]; RFS, 74% vs 62.8% [P = .17]). CONCLUSIONS: Achievement of a pathologic CR vs non-CR in response to LRT before liver transplantation for HCC is associated with improved OS from time of listing and improved RFS after liver transplantation. However, current imaging paradigms fall short of accurate delineation of response to LRT, resulting in poor correlation of outcomes between pathologic and radiologic CR.

Impact of a Monthly Compliance Review on Interventional Radiology Adverse Event Reporting.

PURPOSE: Our aims were to analyze the change in interventional radiology physician major adverse event (AE) reporting after initiation of a monthly morbidity and mortality (M&M) conference compliance review and to describe the association of procedure class and potentially preventable errors with major AE occurrence. METHODS: In late 2010, to motivate timely reporting, we instituted a structured monthly M&M conference review confirming whether each complication warranted institutional AE reporting and whether timely reporting had occurred. In this study, we retrospectively analyzed the M&M conference minutes over the subsequent 5 years. Logistic regression was used to model the change of AE reporting over time as well as the association of procedure class with the risk of an AE. Each AE was classified as to whether it seemed potentially preventable. RESULTS: There were 46,660 patient encounters, 1,160 (2.5%) major and minor complications, and 462 (1.0%) reportable AEs. From 2011 to 2015, the percentage of reportable AEs reported increased from 67% to 98%. The number of months from initiation of the M&M conference review was a significant predictor of the likelihood of AE reporting (odds ratio 1.06, 95% confidence interval 1.04, 1.08, P < .0001). Procedure class was strongly associated with the risk of a reportable AE (P < .0001). At least 111 (24%) reportable AEs were potentially preventable. CONCLUSIONS: Increasing AE reporting occurred after initiation of a monthly M&M conference compliance review. The incidence of reportable AEs was strongly associated with procedure class, and a significant percentage of these events were potentially preventable.

The Impact of Bridging LRT on Survival in Patients Listed for Liver Transplantation.

PURPOSE: Locoregional therapy (LRT) is recommended for certain groups of patients with hepatocellular carcinoma (HCC) listed for orthotopic liver transplantation (OLT) with expected wait times greater than 6 months. A retrospective single-center study was performed to evaluate the effect of LRT on the outcomes of patients with HCC listed for OLT. METHODS: Institutional database was reviewed to identify the patients listed for OLT with HCC (March 1998-December 2010). Patient and tumor characteristics were recorded with a follow-up period of 6.5 years from diagnosis. RESULTS: Out of 359 listed patients, 72 patients were delisted (delisted group) and 287 underwent orthotopic liver transplantation (OLT group). One hundred fifty-five and 45 patients from the OLT and delisted groups underwent locoregional therapy (LRT), respectively. Median wait time and sum of largest tumor diameter were significantly higher for patients receiving LRT. LRT was associated with significantly better survival among delisted patients at the end of follow-up (1249.6 ± 137.4 vs. 742.1 ± 155.4 days, p = 0.028). In the OLT group, survival was similar between LRT and no LRT group, but survival was significantly better in patients with largest tumor diameter ≥30 mm (1949.4 ± 95.1 vs. 1694.8 ± 135.5, p = 0.02). CONCLUSION: Patients with HCC and the largest tumor greater than 30 mm treated with LRT prior to OLT have improved survival compared to patients not receiving LRT. Additionally, for patients who did not undergo transplant survival is significantly longer for those receiving LRT.

Effect of Substituting 50% Isovue for Sterile Water as the Delivery Medium for SIR-Spheres: Improved Dose Delivery and Decreased Incidence of Stasis.

PURPOSE: The objective of this study was to evaluate the effect of substituting 50% Isovue (Bracco Diagnostics Inc, Monroe Township, NJ) for sterile water on the delivery of Y resin microspheres (SIR-Spheres [Sirtex Medical Limited, Sydney, Australia]). MATERIALS AND METHODS: The authors retrospectively reviewed all SIR-Spheres radioembolizations at the authors' institution from January 1, 2011, to February 10, 2014. From January 1, 2011, to April 30, 2013, all users performed SIR-Spheres radioembolization per the manufacturer's original instructions using sterile water in the B and D lines and intermittently checking the progress of the embolization by injecting contrast via the B line. Beginning May 1, 2013, a modified technique using Isovue diluted 50% with saline in place of sterile water in both the B and D lines of the infusion set. The authors compared the prepared versus administered activity of Y SIR-Spheres, fluoroscopy time, administration time, and frequency of radioembolizations terminated for stasis when using water versus dilute contrast in the B and D lines. RESULTS: One hundred seventy-five radioembolizations were performed, 132 (75%) with water as the delivery medium and 43 (25%) with 50% contrast as delivery medium. The mean percentage of the Y activity administered was 98% with contrast versus 87% with water (P < 0.01). More than 95% of cases using contrast resulted in 90% or more delivery of the prepared Y activity versus 59% of cases with water (P < 0.01). For cases using water, 17% were terminated for stasis, whereas 2% (1 case) using contrast was terminated for stasis. The mean Y administration time was 7 minutes with contrast versus 22 minutes with water (P = 0.015). Excluding the 37 cases involving coil embolization, the mean fluoroscopy time was 8.3 minutes with contrast versus 11.5 minutes with water (P < 0.05). No complications occurred with the contrast method; however, there were 4 complications with water, including 1 nontarget gastric ulceration. CONCLUSIONS: Using dilute contrast as the delivery medium for SIR-Spheres resulted in a significantly greater percentage of the prepared activity administered to the patient with substantially shorter administration time. Termination for stasis occurred less often with dilute contrast. No complications were observed when using dilute contrast, which allowed continuous real-time monitoring of the Y microsphere administration.

Percutaneous biliary drainage effectively lowers serum bilirubin to permit chemotherapy treatment.

PURPOSE: For digestive tract cancers, the bilirubin threshold for administration of systemic chemotherapy can be 5 or 2 mg/dL (85.5 or 34.2 µmol/L) depending upon the regimen. We examined the ability of percutaneous biliary drainage (PBD) in patients with malignant biliary obstruction to achieve these clinically relevant endpoints. METHODS: 106 consecutive patients with malignant biliary obstruction and a baseline serum bilirubin >2 mg/dL underwent PBD. Time to achieve a bilirubin of 5 mg/dL (85.5 µmol/L), 2 mg/dL (34.2 µmol/L), and survival was estimated by Kaplan-Meier analysis. Potential technical and clinical prognostic factors were subjected to univariate and multivariate analysis. Categorical variables were analyzed by the log rank test. Hazard ratios were calculated for continuous variables. RESULTS: Median survival was 100 days (range 1-3771 days). Among 88 patients with a pre-drainage bilirubin >5 mg/dL, 62% achieved a serum bilirubin ≤5 mg/dL within 30 days and 84% within 60 days, median 21 days. Among 106 patients with a pre-drainage bilirubin >2 mg/dL, 37% achieved a serum bilirubin ≤2 mg/dL by 30 days and 70% within 60 days, median 43 days. None of the technical or clinical factors evaluated, including pre-drainage bilirubin, were significant predictors of time to achieve a bilirubin ≤2 mg/dL (p = 0.51). Size and type of biliary device were the only technical variables found to affect time to bilirubin of 5 mg/dL (p = 0.016). CONCLUSION: PBD of malignant obstruction achieves clinically relevant reduction in serum bilirubin in the majority of patients within 1-2 months, irrespective of the pre-drainage serum bilirubin, sufficient to allow administration of systemic chemotherapy. However, the decision to undergo this procedure for this indication alone must be considered in the context of patients' prognosis and treatment goals.

Recurrent Bleeding, Survival, and Longitudinal Pulmonary Function following Bronchial Artery Embolization for Hemoptysis in a U.S. Adult Population.

PURPOSE: To report outcomes of bronchial artery embolization (BAE) for hemoptysis, including recurrent bleeding, survival, and longitudinal pulmonary function. MATERIALS AND METHODS: A prospective database identified 69 patients who underwent 97 BAE procedures (n = 1-7 per patient) at a tertiary academic medical center over a period of 11 years. Technical and clinical success were determined. Recurrent bleeding and survival were compared by etiology of lung disease. Rates of change in pulmonary function (forced expiratory volume in 1 s [FEV1] and forced vital capacity [FVC]) were measured and compared before and after index BAE by linear regression in 17 patients. RESULTS: The technical success rate of BAE was 90%. Clinical success rates at 24 hours and 30 days were 82% and 68%, respectively. Thirty percent of patients had recurrent bleeding that required bronchoscopy (7%) or additional embolization (23%). Median time to recurrent bleeding was 29 days among the 13 patients with sarcoidosis, compared with 293 days among patients without sarcoidosis (P = .0013). The hazard ratio for death in patients with sarcoidosis compared with those without sarcoidosis was 4 (95% confidence interval, 2.6-14.6). Analyzing all instances of pulmonary function tests, slopes of decline in FEV1 and FVC were significantly different (FEV1, P = .0048; FVC, P < .0001) before and after index BAE, with an improvement after BAE (FEV1, 0.8%/y; FVC, 1%/y) and a decrease before BAE (FEV1, -1.6%/y; FVC, -1.4%/y). CONCLUSIONS: BAE is an effective therapy for hemoptysis, but patients with sarcoidosis are at significant risk of recurrent bleeding and death compared with patients with other lung diseases. BAE does not accelerate deterioration in lung function.

Initial Clinical Experience: Symmetric-Tip Dialysis Catheter with Helical Flow Characteristics Improves Patient Outcomes.

PURPOSE: To report preliminary clinical experience with a new symmetric-tip dialysis catheter compared with a conventional split-tip catheter. MATERIALS AND METHODS: Over a 5-month period, patients requiring a tunneled catheter for hemodialysis or undergoing exchange of a dysfunctional dialysis catheter at a tertiary academic medical center were retrospectively analyzed. Patients underwent placement of a VectorFlow or Ash Split Cath catheter at the discretion of the inserting interventional radiologist. Patient demographics, catheter patency, mean blood flow rate, and arterial and venous pressures were compared according to catheter type. Catheter failure was analyzed based on clinical and anatomic variables by using a multivariate Cox proportional-hazards model. RESULTS: A total of 33 VectorFlow and 46 Ash Split Cath catheters were placed. Patients in the VectorFlow group had significantly higher body mass index (P = .013) and Charlson Comorbidity Index (P = .049), as well as more non-internal jugular vein placements. At 120 days, 89% of VectorFlow catheters remained functional, compared with 45% of Ash Split Cath catheters (P = .046). The VectorFlow catheter was associated with 16% lower arterial pressures during dialysis (P = .009); mean blood flow rate was equivalent. On multivariate analysis, the risk of catheter failure was 13.3 times higher in the Ash Split Cath group compared with the VectorFlow group (P = .004). Left-sided catheters were also predictive of catheter failure (relative risk = 5.5; P = .02). CONCLUSIONS: The VectorFlow catheter was associated with a significant increase in intervention-free catheter patency compared with the Ash Split Cath catheter, with equivalent flow at lower arterial pressures during dialysis.

Long-term outcomes of a benign biliary stricture protocol.

PURPOSE: To evaluate long-term outcomes of a structured protocol for percutaneous treatment of benign biliary stricture. MATERIALS AND METHODS: Seventy-one patients (37 men, 34 women; mean age, 54 y; age range, 23-84 y) entered the protocol, which consisted of staged upsizing of internal/external biliary catheters, balloon dilation (nominally 8 mm), and prolonged stent treatment (6 mo) at maximal catheter size (nominally 18 F). It concluded with a capping trial and catheter removal if the stricture remained patent. Fifty-three patients completed the protocol and 18 did not (6 died, 6 underwent alternative treatment, 4 were lost to follow-up, and 2 underwent repeat transplantation). Stricture features, treatment parameters, complications, and outcomes were reviewed, and Kaplan-Meier analysis was conducted. RESULTS: Strictures were anastomotic in 45 patients (64%), intrahepatic in 14 (20%), extrahepatic in 7 (10%), and multiple (intra- and extrahepatic) in 5 (7%). A right-sided approach was used in 47 patients (66%) patients, a left-sided approach in 18 (25%), and a bilateral approach in 6 (9%). Forty-six patients who entered the protocol (65%) and 46 patients who completed the protocol (87%) showed stricture patency. Four of 7 patients in whom a capping trial failed underwent surgical revision, 2 required chronic biliary drainage, and 1 received a metal stent. Follow-up (range, 0-12 y; mean, 4.7 y) was obtained for 42 of 53 patients who completed the protocol (79%). Kaplan-Meier analysis showed stricture patency probabilities of 84% at 1 year after treatment, 78% at 2 years, 74% at 5 years, and 67% at 10 years. CONCLUSIONS: Use of a structured protocol for the percutaneous treatment of benign biliary strictures yields durable long-term results, suggesting that percutaneous treatment is an effective therapy.

Effect of central venous angioplasty on hemodialysis access circuit flow: prospective study of 25 symptomatic patients.

PURPOSE: To quantify the effect of central venous percutaneous transluminal angioplasty (PTA) on blood flow within hemodialysis access circuits in patients with symptomatic central venous stenosis (CVS). MATERIALS AND METHODS: This prospective study enrolled 30 adults with symptoms attributable to CVS ipsilateral to their access. Five subjects were deregistered because of a lack of CVS (n = 1), untreatable lesion (n = 1), or improper flow measurement timing (n = 3); 25 completed the study (15 men and 10 women; mean age, 62 y; age range, 33-87 y). There were 7 fistulae, 15 grafts, and 3 hybrid access circuits. Mean access age was 675 days (range, 16-3,039 d). Mean CVS symptom duration was 37 days (range, 3-120 d). Peripheral stenoses, if present, were treated first. Intraaccess flow was measured immediately before and immediately after CVS treatment (PTA, stent). RESULTS: Eleven patients had only CVS, whereas 14 had at least 1 peripheral lesion in addition to CVS. All stenoses underwent PTA. Mean flow rates were 1,424 mL/min (range, 565-2,765 mL/min) before PTA and 1,535 mL/min (range, 598-2,545 mL/min) afterward, yielding a mean increase of 111 mL/min ± 456 or 15% ± 34 (range, -70% to +100%; 95% confidence interval, 1%-29%). Flow was decreased in 9 patients (36%). CVS symptoms were reduced in 24 patients (96%) and recurred in 14 (58%) within a mean of 110 days (range, 7-459 d) after initial PTA. Mean follow-up was 371 days (range, 17-592 d). CONCLUSIONS: CVS symptoms were observed to occur over a wide range of blood flow rates. On average, central venous PTA only mildly increased flow yet reduced symptoms regardless of flow change.

Risk of liver abscess formation in patients with prior biliary intervention following yttrium-90 radioembolization.

PURPOSE: Patients without a competent sphincter of Oddi due to prior surgical or endoscopic therapy are at high risk for liver abscess following chemoembolization despite aggressive antimicrobial prophylaxis. We examined a cohort of such patients undergoing Y-90 resin radioembolization and compared them to a cohort of chemoembolized patients. METHODS: Review of our quality-assurance database identified 24 radioembolizations performed in 16 patients with prior biliary intervention. An aggressive prophylactic regimen of oral levofloxacin and metronidazole 2 days pre-procedure continuing for 14 days after, oral neomycin/erythromycin bowel prep the day before, and IV levofloxacin/metronidazole the day of treatment was prescribed. Patients underwent resin microsphere radioembolization dosed according to the BSA method. Patients had clinical, imaging, and laboratory assessment 1 month after each treatment, and then every 3 months. The chemoembolization cohort consisted of 13 patients with prior biliary intervention who had undergone 24 chemoembolization procedures. RESULTS: No radioembolization patient developed an abscess. In the cohort of chemoembolized patients who received the same prophylaxis, liver abscess occurred following 3 of 24 (12.5 %) procedures in 3 of 13 (23 %) patients, one fatal. CONCLUSIONS: This preliminary experience suggests that the risk of liver abscess among patients with prior biliary intervention may be lower following radioembolization than chemoembolization, which could potentially expand treatment options in this high-risk population.

Diagnostic yield of transjugular liver biopsy samples to evaluate for infectious etiology of liver dysfunction in bone marrow transplant recipients.

PURPOSE: To determine the diagnostic yield of transjugular liver biopsy (TJLBx) samples to evaluate for infectious etiology (immunosuppressed protocol [ISP] of TJLBx) in bone marrow transplant (BMT) recipients. METHODS: A retrospective review of 78 TJLBx in 61 patients who had undergone BMT was undertaken. Biopsy was performed with an automated 19-gauge needle set. The primary indication was suspected graft-versus-host disease in all; a subset also sought to detect infectious liver pathology. In these (n = 31 biopsy samples, 22 patients), an ISP was used with tissue sent for bacterial, viral, fungal, and mycobacterial analysis in addition to histology. In the remainder (n = 47 biopsy samples, 41 patients), tissue was sent for histology only (H). Sample adequacy, histological diagnosis, microorganism assay results (ISP), and complications were reviewed. To assess sample adequacy in BMT compared to non-BMT patients, random control sample of 77 biopsy samples in 75 inpatients during the same period was reviewed (C). RESULTS: All but 1 TJLBx (C group) were technically successful (99%). One major (ISP) and 5 minor complications occurred (H = 3, ISP = 1, C = 1). There were 3 inadequate specimens (6.4%) in the H group, 4 in the ISP group (12.9%), and 4 in the C group (5.2%) (p = NS). No organisms were isolated in any ISP biopsy samples (yield 0%). CONCLUSION: When ISP is requested in BMT recipients, biopsy yields were lower, for unclear reasons possibly relating to degree of liver injury. ISP adds no useful positive information over histology alone. The value of negative cultures in this population is unclear.